As the incidence of CKD increases, so will the ESRD population. Pre-ESRD care, including early referral to nephrology and patient education, enables patients and providers working together to determine which therapy modality is best suited for their individualized needs: conservative therapy, kidney transplant, hemodialysis, or peritoneal dialysis. Differentiating the therapy modality should be based on many factors and not solely based on outcome data. Acknowledging that there is no "one-size-fits-all" therapy modality allows the patient and the interdisciplinary team to ensure that the appropriate access is chosen at the appropriate time. Lastly, the timing of initiation is paramount for improving patient outcomes, including less central venous catheter placement in incident hemodialysis and more planned arteriovenous accesses, improved quality of life, less hospitalization time, and reduced costs.